. TUBERCULOSIS Caused by bacteria belonging to the Mycobacterium tuberculosis complex The disease usually affects the lungs, although in up to one-third of cases other organs are involved Transmission usually takes place through the air borne spread of droplet nuclei produced by patients with active pulmonary tuberculosis T.B The bacillus causing tuberculosis, Mycobacterium tuberculosis, was identified and described on 1882 by Robert Koch. He received the Nobel Prize in 1905 for this discovery1882Robert Koch Nobel Prize ETIOLOGIC AGENT the most frequent and important agent of human disease is M. tuberculosis. The complex includes: M. bovis the bovine tubercle bacillus, (the cause of a small percentage of cases in developing countries), M. africanum M. microti M. canettii . the extrapulmonary sites most commonly involved in tuberculosis are; pleura, the lymph nodes genitourinary tract, bones,joints, meninges, peritoneum,and pericardium TB OF ELBOW JOINT TB OF ELBOW . SKELETAL TUBERCULOSIS the pathogenesis is related to a- reactivation of hematogenous foci b- spread from adjacent paravertebral lymph nodes: 1-Weight-bearing joints (spine, hips, and knees in that order) are affected most commonly. 2-Spinal tuberculosis (Potts disease or tuberculous spondylitis); often involves two or more adjacent vertebral bodies. TB SPINE the upper thoracic spine is the most common site of spinal tuberculosis in children, the lower thoracic and upper lumbar vertebrae are usually affected in adults. With advanced disease, collapse of vertebral bodies results in kyphosis (gibbus). A paravertebral cold abscess may also form In the upper spine, this abscess may track to the chest wall as a mass; in the lower spine, it may reach the inguinal ligaments or present as a psoas abscess. -(CT) or (MRI) reveals the characteristic lesion and suggests its etiology, Aspiration of the abscess or bone biopsy conrms the tuberculous etiology, as cultures are usually positive and histologic ndings are highly typical. -a catastrophic complication of Potts disease is paraplegia, which is usually due to an abscess or a lesion compressing the spinal cord. Paraparesis due to a large abscess is a medical emergency and requires abscess drainage. Exrtapulmonary TB Mx Skeletal tuberculosis responds to chemotherapy, but severe cases may require surgery. the diagnosis is rst suspected by chest radiograph it shows the typical picture of upper lobe inltrates with cavitation A presumptive diagnosis is commonly based on the nding of AFB on microscopic examination of a diagnostic specimen such as 1-a smear of expectorated sputum 2-or of tissue (for example, a lymph node biopsy). Denitive diagnosis depends on the isolation and identication of M. tuberculosis from a diagnostic specimen. 4 to 8 weeks may be required before growth is detected. TREATMENT Short-course regimens are divided into an initial, or bactericidal, phase and a continuation, or sterilizing, phase. During the initial phase, the majority of the tubercle bacilli are killed, symptoms resolve, and the patient becomes noninfectious. The continuation phase is required to eliminate persisting mycobacteria and prevent relapse. - The treatment regimen of choice for virtually all forms of tuberculosis consists of a 2-month initial phase OF Isoniazid, Rifampin, Pyrazinamide, and Ethambutol (4*2) FOLLOWED BY 4 month continuation phase of Isoniazid and Rifampin.(2*4) Treatment may be given daily or intermittently extrapulmonary tuberculosis - can be treated with the 6 month regimen recommended for patients with pulmonary disease VIRAL ARTHRITIS are self-limiting The usual presentation is with acute polyarthritis, fever or viral prodrome and rash. Diagnosis is confirmed by a rise in specific IgM. Polyarthritis may also rarely occur with hepatitis B and C, rubella and HIV infection. Psoriatic arthritis (PsA) occurs in 720% of patients with psoriasis and in up to 0.6% of the general population. The onset is usually between 25 and 40 years of age. Most patients (70%) have pre-existing psoriasis but in 20% the arthritis predates the occurrence of skin disease. Occasionally, the arthritis and psoriasis develop synchronously.. Clinical features The presentation is with pain and swelling affecting the joints and entheses. Several patterns of joint involvement are recognised but the course is generally one of intermittent exacerbation followed by varying periods of complete or near-complete remission. Destructive arthritis and disability are uncommon, except in the case of arthritis mutilans Types of joints involvement 1-Asymmetrical inflammatory oligoarthritis (sero-ve like) affects about 40% of patients and often presents abruptly. This occurs most characteristically in the hands and feet, when synovitis of a finger or toeis coupled with tenosynovitis, enthesitis and inflammation of intervening tissue to give asausage digit or dactylitis. Large joints, such as the knee and ankle, may also be involved, sometimes with very large effusions. Types of joints involvement 2-Symmetrical polyarthritis (RA) occurs in about 25% of cases. It predominates in women and may strongly resemble RA, with symmetrical involvement of small and large joints in both upper and lower limbs. Nodules and other extra-articular features of RA are absent and arthritis is generally less extensive and more benign. Much of the hand deformity often results from tenosynovitis and soft tissue contractures(how to differentiate) Types of joints involvement 3-Psoriatic spondylitis (AS)like presents a similar clinical picture to AS but with less severe involvement. It may occur alone or with any of the other clinical patterns described above and is typically unilateral or asymmetric in severity. Types of joints involvement 4-Distal IPJ arthritis (the typical type) is an uncommon but characteristic pattern affecting men more often than women. It targets finger DIP joints and surrounding periarticular tissues, almost invariably with accompanying nail dystrophy. Types of joints involvement 5-Arthritis mutilans (occurs in 5% of cases of PsA) is a deforming erosive arthritis targeting the fingers and toes that Prominent cartilage and bone destruction results in marked instability. The encasing skin appears invaginated and telescoped (main en lorgnette) and the finger can be pulled back to its original length Arthritis mutilans Nail changes include pitting, onycholysis, subungual hyperkeratosis and horizontal ridging. They are found in 85% of those with PsA and only 30% of those with uncomplicated psoriasis, and can occur in the absence of skin disease. The characteristic rash of psoriasis may be widespread, or confined to the scalp, natal cleft and umbilicus, where it is easily overlooked. Conjunctivitis can occur, whereas uveitis is mainly confined to HLA-B27-positive individuals with sacroiliitis and spondylitis Investigations The diagnosis is made on clinical grounds. Autoantibodies are generally negative and acute phase reactants, such as ESR and CRP, are raised in only a proportion of patients with active disease Investigations X-rays may be normal or show erosive change with joint space narrowing. Features that favour PsA over RA include the characteristic distribution of proliferative erosions with marked new bone formation, absence of periarticular osteoporosis and osteosclerosis Investigations MRI and ultrasound with power Doppler are increasingly employed to detect synovial inflammation and inflammation at the entheses. Management NSAID and analgesics may be sufficient to control symptoms in mild disease. Intra-articular steroid injections can control synovitis. Management Splints and prolonged rest should be avoided because of the tendency to fibrous and bony ankylosis. Patients with spondylitis should be prescribed the same exercise and posture regime as in AS. Management Therapy with DMARDs should be considered for persistent synovitis unresponsive to conservative treatment. Methotrexate is the drug of first choice since it may also help skin psoriasis Management but other DMARDs may also be effective, including sulfasalazine, ciclosporin and leflunomide. Hydroxychloroquine is generally avoided, as it can cause exfoliative skin reactions. Management Anti-TNF treatment for patients with active synovitis who respond inadequately to standard DMARDs. This is effective for both PsA and psoriasis. Other biological treatments, such as ustekinumab, are emerging, which target the IL- 12/23 receptor. Ustekinumab is highly effective in the treatment of psoriatic skin disease and is often effectve in PsA JUVENILE IDIOPATHIC ARTHRITIS JIA (also JCA.JRA)is the most common form of childhood arthritis. -it is of unknown etiology. Prevalence per Of childern younger than 16 years. 50 % has active disease that persist into adulthood. To Dx JIA arthritis must be present for at least 6/52 There is no specific test - The Dx is by exclusion JIA is subdivided into many categories 1-Systemic(Still s) 2-17 % 2-Polyarticular RF+ve 2-10 % 3-Polyarticular RF-ve 10-28% 4-Oligoarthritis (persistant) 12-30% 5-Oligoarticular (extended) 12-30% 6-Enthesitis related arthritis 3 -10% 7-Psoriatic arthritis 2-10% 8-Undifferentiated 2-20% % Systemic (or Still s disease) it was discribed by Still in arthritis + fever - NON pruritic rash -generalized LAP -HSM -serositis -M:F 1:1 -leukocytosis -vasculitis is a complication - uveitis is rare OLIGOARTHRITIS - arthritis 5 joints ANA +ve females with persistent oligoarticular JIA are at high risk of uveitis (30-50%) and slit lamp eye examination is recommended UVEITIS PSORIATIC ASSOCIATED JIA -arthritis + psoriasis in patient < 16 years old - only 10% of patients has the onset of psoriatic rash and arthritis at the same time -nail finding is evident (pitting,onycholysis& dactilitis) -uveitis risk is 20% psoriasis Nail changes in psoriasis ENTHESITIS RELATED ARTHRITIS -arthritis -enthesitis -sacroiliac j involvement -+ve HLA-B27 -uveitis up to 25% -enthesitis is inflammation of tendon insertion,ligaments or fascia insertion into the bone -aortic involvement may occur Enthesitis Inflammatoty arthritis in children is much less common than in adult. there is no specific test which definitely prove the diagnosis. Etiology is unknown. The most recent classification is the international league rheumatism(ILAR) JRA POLYARTICULAR JRA KNEE EFFUSION PROGNOSIS The disease is active in up to 35 % of children after 10 years follow up and 30% have erosive arthritis. Reported remission rate for JIA in 5-10 year follow up studies confirm the differential between oligoarticular (40-80%) polyarticular (20-54% ) and systemic(0-35% in remission)JIA. A MULTIDISCIPLINARY APPROACH IS RECOMMENDED.which involve; rheumatologist, paediatricians, ophthalmologist,dentist,psychologists, physiotherapist, occupational therapist, nurses, social workers and teachers. Physiotherapy will reduce deformity. Rest is indicated when the joints are acuetly inflammed. splints to prevent flexion deformity Hydrotherapy in warm pool is particularly useful. The child should be kept active and ambulant. NSAID are used at higher doses than in adults (approximately 10-20mg/Kg/day of naproxine).Aspirin should be avoided because of the risk of Reye s syndrome. Intra articular steroid injections are used to treat resistant joints.. Methotrixate is added for at least 2 years. -MTX& Sulphasalazine are helpful for polyarticular JIA. Combination therapy is used for resistant cases. Long term corticosteroids are indicated for 1-severe systemic disease (Still s) 2-and for chronic uveitis not responding to local therapy Advanced therapy biologic agents like (TNF-ALPHA inhibitors) Etanercept,Infliximab,Adalimumab are more useful for polyarticular than systemic type. they are now used with excellent response in severe JIA and in uveitis and vasculitis.. - Anti (Interleuken-1)IL-1 ( Anakinra ) & Anti IL-6 (Tocilizumab) are used for systemic onset type Surgery like total hip replacement is indicated for children with severe hip involvement Poor prognosis 1-polyarticular disease. 2-systemic arthritis that evolve into polyarthritis. 3-extended oligiarticular disease. 4- polyarticular disease attributable to psoriatic arthritis. THANKS
